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1 the UK's Pandemic Influenza Research The UK’s pandemic influenza research portfolio: a model for future research on emerging infections Professor Colin R Simpson PhD a b, *, Mr Dan Beever MPH c, Dr Kirsty Challen PhD d, Dr Daniela De Angelis PhD e, Ms Ellen Fragaszy MSc f g, Professor Steve Goodacre PhD h, Professor Andrew Hayward MD f i, Professor Wei Shen Lim DM j, Dr G James Rubin PhD k, Professor Malcolm G Semple PhD l, Professor Marian Knight DPhil m, on behalf of the NIHR hibernated influenza studies collaborative group a Usher Institute, The University of Edinburgh, Edinburgh, UK. b Faculty of Health, Victoria University of Wellington, Wellington, New Zealand. c. Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK d. Lancashire Teaching Hospitals NHS Trust and Honorary Senior Lecturer, Centre for Urgent and Emergency Care Research, University of Sheffield, UK e MRC Biostatistics Unit, University of Cambridge f Centre for Public Health Data Science, Institute of Health Informatics, University College London, London, UK g Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK h Centre for Urgent and Emergency Care Research, School of Health and Related Research (ScHARR), University of Sheffield i Institute of Epidemiology and Health Care, University College London, London, UK j Nottingham University Hospitals NHS Trust, Nottingham, UK k Department of Psychological Medicine, Weston Education Centre, King’s College London, London, UK l Institute of Translational Medicine, University of Liverpool, UK m National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK * Corresponding author NIHR hibernated influenza studies collaborative group: Marian Knight, Colin R Simpson, Dan Beever, Kirsty Challen, Daniela De Angelis, Ellen Fragaszy, Steve Goodacre, Andrew Hayward, Wei Shen Lim, Garry Meakin, G James Rubin, Malcolm G Semple, Helen Walters. 1 Summary The 2009 A/H1N1 influenza pandemic was responsible for considerable global morbidity and mortality. In 2009, UK funders, including the National Institute for Health Research (NIHR) rapidly funded and activated a number of research studies to inform clinical and public health actions. However, even with accelerated processes, some studies were completed too late for their results to have an early and significant impact on clinical care. This was in contrast to a study funded separately in 2008, which was published within a matter of weeks after the first two cases of 2009 A/H1N1 influenza virus infection were detected in the UK. In recognition of the impact of the NIHR-funded 2009 A/H1N1 influenza work and following reflection on the inherent delays in calling for research proposals, assessing, funding, and setting up the subsequent projects, including obtaining relevant ethical and regulatory approvals, the NIHR funded a second wave of studies in 2012. Our portfolio of projects have now been set-up (relevant permissions put in place, arrangements made for data collection) and pilot tested where relevant. All studies are now in ‘hibernation’ - that is, they have been put on standby mode in a maintenance-only state to await activation in the event of a pandemic being declared. In this thought piece, we describe the projects that were set up, the challenges of putting these projects into hibernation, on-going activities to maintain readiness for activation, and discuss how we think about planning research for a range of major incidents (e.g. other emerging infectious diseases, chemical, biological, radiological or nuclear (CBRN) risks, extreme weather events or industrial accidents). 2 Introduction In response to the 2009 A/H1N1 influenza pandemic, the UK’s funders, including the National Institute for Health Research (NIHR) rapidly sponsored and activated a number of research studies to inform clinical and public health actions (Table 1). That programme demonstrated the ability of the NIHR to commission, fund and deliver clinically relevant research under challenging circumstances [1]. However, even with accelerated processes, some studies were completed too late for their results to have an immediate significant impact on clinical care [2- 4]. This experience was shared by major research networks in other countries [5]. In contrast, studies which had been funded separately, either prior to the emergence of the pandemic [6] or via Department of Health in England were able to provide timely reports on their results [7]. In recognition of the impact of the NIHR-funded 2009 A/H1N1 influenza work, and following reflection on the inherent delays in calling for research proposals, assessing, funding and setting up the subsequent projects, including obtaining relevant ethical and regulatory approvals, the NIHR funded a second wave of studies in 2012. These projects were set up (relevant permissions put in place, arrangements made for data collection) and pilot tested where relevant. All of the studies are being maintained in a state of readiness or ‘hibernation’ in that they are on standby mode in a maintenance-only state to await activation in the event of a pandemic being declared. Other organisations have subsequently recognised the need for better planning of research for future pandemics [8]. The NIHR CRN portfolio of pandemic influenza studies The portfolio of studies (Table 1) cover key pathways of healthcare for influenza illness, including: surveillance, primary prevention (vaccination), triage (both in the community and at the hospital front door) and clinical management (therapeutics). 3 The population-level susceptibility, severity and spread of pandemic influenza study (PIPS) has developed the Health Survey for England as a tool for rapid population based serological surveys of influenza infection and disease [9]. During the first two waves of a pandemic, the study will assess the public’s susceptibility to and spread of the novel virus both geographically and by age. By combining our estimated number of infections in the population with estimates of the numbers of hospitalisations and deaths, we can quantify the proportion of infections leading to these outcomes – a key measure of pandemic severity. The Flu Telephone Survey Template study (FluTEST) has been funded to develop rapid turn- around telephone surveys, for use in monitoring behaviour across the general population and identifying ways of improving how we communicate our public health advice [10]. How the public behave during any future pandemic will play a crucial role in how quickly influenza spreads in our community. Understanding whether the public are adhering to public health recommendations e.g. washing hands, being vaccinated and using health services appropriately, and if not, why not, is essential information [6][10-11] The EAVE (Early estimation of pandemic influenza Antiviral and Vaccine Effectiveness) project has created a new sentinel system linking primary care data to RT-PCR swabs, stored serology and hospital and mortality outcomes. The EAVE sentinel system, which builds on the seasonal influenza vaccination study SIVE [12], allows rapid evaluation of any new vaccination (and antivirals). EAVE also provides information to help with targeting any available pandemic influenza vaccine at those who are considered to be at increased risk of serious illness or death from pandemic influenza infection e.g. those with any underlying medical conditions; those who may lack cross-reactivity from exposure to previous pandemics or vaccinations; and novel risk groups that are uniquely at risk because of a tropism exhibited by the virus [13]. For any new pandemic influenza vaccine, it may take some time until matched vaccines are available. Stockpiled pre-pandemic vaccine (e.g. H5, H7) for the UK population, 4 recommended to be of sufficient quantities for those aged 16 or under and aged 65 or over could be used for early testing [14,15]. The FLU-CATs (real time refinement and validation of criteria and tools used in primary care) study captures the criteria that allows validation of several triage tools in the early stage of an outbreak in readiness for deployment of these tools should surge occur [16]. During pandemics, surge in health-care demand can exceed capacity to provide normal standards of care. Health- care workers who are unfamiliar with clinical assessment and admission decision-making may be asked to fulfil ‘gatekeeper’ roles. Triage tools may aid decisions in identifying people who are most likely to benefit from the higher levels of care that can only be provided in hospital. Anonymised details of patients with influenza-like-illness attending a study general practice will be shared with the study team. These details include: assessment, management, selected medical record excerpts, record hospital discharge data and death notices [16]. FLU-CATs activates during winter influenza seasons at a limited number of sites (5 to 20) to maintain study processes. This has allowed validation of the Department of Health Community Assessment Tools for use in children and adults presenting with seasonal influenza like illness The PAINTED study (PAndemic INfluenza Triage in the Emergency Department) addresses the issue of needing to prioritise a potentially large number of patients with limited resources in the event of a pandemic [17]. Clinicians will need to identify patients at higher risk of poor outcomes, ideally with minimal or no supplementary testing. This study will use a standardised clinical assessment form
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